Chapter 25: Assessing Neurologic System
The nurse is performing the Romberg test. Which of the following indicate a normal finding? -Client stands erect with minimal swaying -Client sways when eyes are closed -Client prevents himself from falling -Client maintains balance when walking
Client maintains balance when walking
When assessing deep tendon reflexes in an elderly client what finding would the nurse anticipate?
Decreased reaction time
During assessment, the nurse notes the client has limited movement of his lower extremities and sways when standing with feet together. The nurse identifies that the client is at risk for what?
Falls
T/F After testing deep tendon reflexes, the nurse documents 2+. The nurse should evaluate further.
False
Which part of the brain controls the vital functions of temperature, heart rate, blood pressure, sleep, the anterior and posterior pituitary, the autonomic nervous system, and emotions and maintains overall autonomic control?
Hypothalamus
The nurse assesses the motor system as part of the full neurological examination. In order to effectively assess this system, which of the following instructions should be given to the client? -Instruct the client to state the current date and place -Instruct the client to flex and extend the right elbow -Instruct the client to smile -Ask the client to close the eyes
Instruct the client to flex and extend the right elbow
When performing an assessment of the nervous system, it is most appropriate for a nurse to complete it in which sequence?
Mental status, cranial nerves, motor/cerebellar, sensory, reflexes
A nurse is with a client who is victim of a shooting. The client has an increased pulse rate and pupil dilation and is clearly in stress. The nurse recognizes the "fight-or-flight" response in this client and understands that this represents an activation of which system?
Sympathetic nervous system
When conducting a Romberg test, why does the nurse ask the client to stand feet together with eyes open and then closed?
Vision can compensate for loss of position sense.
